Universities are key social institutions that shape student health, wellbeing, and future trajectories. However, they are also embedded in, and contribute to, existing social inequities. Students holding marginalised positions consistently report experiences of discrimination within higher education. Such experiences adversely affect their mental health, sense of belonging, and academic trajectories. Much of this research relies on single-axis analyses, failing to capture the complexity of discrimination. Therefore, this study takes an intersectional, qualitative multi-level approach to explore how university students in Germany experience discrimination during their studies and how this shapes their mental health and wellbeing. Fifteen semi-structured, problem-centred interviews were conducted with university students who reported experiencing discrimination. Data were qualitatively analysed using the Intersectional Multilevel Analysis (IMA) framework by Winker and Degele, linking individual meaning-making and self-positioning to symbolic representations and social structures. Our approach combined inductive reconstruction of students’ self-positionings with deductive contextualisation of how discrimination operates across interpersonal, institutional, and structural levels. Students experienced discrimination as an embodied process shaped by microaggressions, institutional rigidity, and unequal power relations – particularly within student–lecturer dynamics. These dynamics involved intersecting forms of inequity, including racism, sexism, xenophobia, classism, language-based exclusion, ableism, caregiving discrimination, and ageism, experienced not as isolated categories but as overlapping, context-dependent processes. Participants described how the experienced discrimination settled into the body through emotional, cognitive, and physical manifestations expressed as fear, anger, exhaustion, and burnout, accompanied by existential questioning and disrupted identities. These embodied effects were not isolated reactions but ongoing responses to inequity. Alongside these harms, students exercised agency through strategies of endurance, withdrawal and resistance as forms of embodied survival work in response to persistent inequities. Overall, discrimination emerged as a relational and institutional process involving fluid interpersonal dynamics and contextual negotiations through which students’ academic trajectories and relationships to power are continuously (re)produced. Discrimination in higher education must be recognised as not only a social issue, but also a critical public health concern determining students' mental health and wellbeing. Addressing its embodied consequences demands institutional accountability and policies that move beyond symbolic diversity rhetoric toward meaningful structural and cultural transformation.
Women are markedly underrepresented among blood donors in the Eastern Mediterranean Region (EMR), where they account for a median of only about 6
Although cervical cancer is a preventable disease, its burden remains disproportionately high globally, predominantly affecting women in low- and middle-income countries because of inequalities in the uptake of cervical cancer screening. Women living with HIV are at substantially higher risk of developing cervical cancer because of persistent human papillomavirus infection, yet the uptake of cervical screening is very low. In Ethiopia, there is limited evidence on the underlying socioeconomic inequality in screening uptake. Therefore, this study aimed to assess socioeconomic inequalities in the uptake of cervical cancer screening among women living with HIV in Ethiopia. This study was a secondary analysis of data from the Ethiopia Population-based HIV Impact Assessment (EPHIA) survey conducted in 2017–2018. 361 women living with HIV aged 25 to 49 years were included in the analysis. Survey-weighted analyses were performed to account for the complex sampling design. Socioeconomic inequalities were assessed using equiplot, concentration curves, concentration indices, the slope index of inequality (SII), and the relative index of inequality (RII). Fairlie decomposition analysis was performed to quantify the contribution of sociodemographic characteristics to wealth-related inequalities in cervical cancer screening uptake. The overall uptake of cervical cancer screening was 15.5
Causal frameworks of intimate partner violence (IPV) emphasize a complex interplay between multilevel determinants. Although patriarchy is conceptualized as structural-level driver of IPV in these causal frameworks, empirical examinations are typically constrained to use of individual-level proxy measures of patriarchy. In response, this study employs a validated index of structural patriarchy in nationally-representative data to examine associations between structural patriarchy and multiple forms of IPV. Using India’s latest National Family Health Survey (NFHS-5, n = 61,180 females, ages 18–49), we examine patterning and prevalence of patriarchy as measured using the structural-level index. Next, we empirically test links between structural patriarchy and past 12-month female IPV victimization by a male partner via survey-weighted mixed effects logistic regression models. Regression models disaggregate by: report of any type of IPV, emotional-only, physical-only, sexual-only, and experience of all forms of IPV. We find positive linear associations between structural patriarchy and report of IPV after adjusting for other social stratification systems (i.e., caste, religion, and wealth), attitudinal and behavioral indicators, and socio-demographic characteristics. As compared to women in districts with lower levels of structural patriarchy, we find that the highest levels of structural patriarchy are associated with 1.9 times the odds of female-reported experience of IPV (any type) (aOR = 1.92 (95
Place of death is a population-level indicator of end-of-life care pathways and health system organization, but its interpretation depends on service availability, care coordination, and patient preferences. In resource-constrained settings, deaths outside healthcare facilities may reflect structural barriers, although mortality records cannot determine whether the recorded location was preference-concordant. This study examined temporal trends and social determinants of health associated with place of death among breast cancer decedents in Brazil over 25 years. Nationwide population-based study using the Brazilian Mortality Information System from 1999 to 2023. The analysis included 339,425 breast cancer-related deaths. The primary outcome was death outside healthcare facilities, comprising deaths recorded at home, in a public place, or in another location, compared with deaths in hospitals or other healthcare establishments. Joinpoint regression assessed trends in annual percentages, while age-standardized rates were presented separately as a measure of population burden. Regional socioeconomic context was examined ecologically using the Human Development Index. Univariate analysis estimated crude descriptive associations. Overall, 286,134 deaths (84.3
Menstrual health is increasingly recognized as a matter of public health, gender equity, and human rights. However, many menstrual health policies remain fragmented or product-centered and insufficiently address legal recognition, stigma, menstrual literacy, equity, and multisectoral governance. In Iran, no unified national menstrual health program currently exists. This study aimed to develop and methodologically appraise a rights-based and equity-oriented National Menstrual Health Management Program for Iran, named PEEN. This study used a multiphase qualitative evidence-synthesis and expert-consensus design. Qualitative content analysis was conducted using 26 individual interviews, including 15 menstruators and 11 key informants, and seven focus group discussions involving 31 participants. A systematic review of global menstrual health policies and programs was used to identify international policy domains and implementation gaps. Qualitative findings and global evidence were mapped and synthesized to develop the preliminary PEEN draft. The program was refined through the Nominal Group Technique with seven expert panel members and three research facilitators. Methodological quality appraisal was conducted using the AGREE II instrument by three independent experts. Qualitative analysis generated 2,776 initial codes, which were abstracted into five themes: recognition of menstruation as a right; menstrual justice, reproductive health, and sustainable development; empowerment in menstrual management; normalization from humiliation to dignity; and moving forward through the development of laws. The systematic review identified 27 eligible documents from 832 records. Integration of local and global evidence resulted in four interdependent PEEN components: Policy, Empowerment, Equity, and Normalization. Expert consensus clarified that PEEN should be presented as national program components rather than sequential steps. All retained components met the predefined 70
Older adults left behind in rural areas due to large-scale migration often serve as the primary caregivers for their adult children with schizophrenia. This study explores their long-term caregiving experiences, focusing on how caregiving responsibilities are distributed within families, how older caregivers find meaning in their role, and how sustained caregiving reshapes their expectations about aging and death. Using a life course perspective, this study conducted semi-structured in-depth interviews with 14 older caregivers in rural Fujian Province, China. Data were analyzed by two researchers using reflexive thematic analysis. Three core themes were identified. First, older adults’ assumption of caregiving responsibilities was the outcome of a family-level division of labor and compromise, driven by the need to sustain the household’s livelihood. Second, the illness of an adult child interrupted that child’s expected social development and independence, compelling older parents to continue intensive caregiving instead of stepping back from family responsibilities in later life, and they drew on fatalistic beliefs to find meaning in this disrupted trajectory. Third, declining physical capacity exacerbated concerns about losing the ability to provide care, while anxiety about care continuity after death led some caregivers to develop unconventional expectations about the order of death. These findings show that long-term caregiving responsibility for people with schizophrenia in rural China falls mainly on older parents, which points to the need for a sustainable community support system that fairly distributes caregiving responsibility among families, communities, and public services.
Guidelines recommend hepatitis C virus (HCV) screening for pregnant women and for children of HCV-viremic mothers. While the Austrian routine prenatal care program comprises screening for human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infection, HCV testing is not included. We assessed viral hepatitis/HIV testing practices, prevalence, and vertical transmission among an at-risk population in Vienna. Children treated for neonatal abstinence syndrome, indicative of maternal substance use (SU) during pregnancy, at our tertiary care center 01/2014–01/2025 and their mothers were included. Pregnancy details, mode of delivery, and demographic/socioeconomic/virologic parameters were retrospectively assessed. Our pediatric cohort comprised 243 children including 5 sets of twins (male: 50.2
Breast cancer is the leading cause of cancer death among Iranian women, yet national screening remains opportunistic and unevenly implemented. This study assessed Iran’s breast cancer screening system to identify gaps and opportunities for establishing an organized, population-based program. We performed a convergent mixed methods study comprising (i) a literature review of 953 records (7 retained) to develop a checklist, (ii) a two round Delphi panel (n = 6) to complete and validate the checklist, and (iii) after finalizing the checklist; the data that were collected from the literature review and from six semi structured interviews with policy makers, oncologists and frontline providers were used to assess the breast cancer screening program in Iran according to the checklist that was developed in the previous stage. Despite the existence of a national guideline and a broad network of screening centers, implementation remains inconsistent, with significant disparities in access, resource allocation, and program reach across provinces. Screening is primarily opportunistic, and manual data management, insufficient dedicated funding, and limited proactive outreach constrain effectiveness. Key performance indicators, such as early detection and follow-up rates, are not systematically monitored. However, the established infrastructure, trained personnel, and ongoing awareness campaigns provide a strong foundation for future improvements. Iran has made notable progress in establishing the foundations of a national breast cancer screening program, but critical gaps persist. Advancing toward an organized, population-based approach will require integrated electronic systems, sustainable funding, workforce development, and robust monitoring frameworks. Piloting an invitation-based model in selected provinces or catchment areas may provide a feasible pathway for gradual national scale-up.
Early childhood development metrics remain substandard among marginalized ethnic minority communities in three border provinces of Thailand. This study evaluated the levels and determinants of health literacy (HL) among primary caregivers to contextualize its role in mitigating adverse child health outcomes. A community-based, cross-sectional correlational study employing multi-stage cluster random sampling was conducted between July and October 2024. Sample size was determined using an a priori power analysis for multiple linear regression (f² = 0.05, α = 0.05, power = 0.80, 19 predictors), yielding a minimum of 351 participants; 380 caregivers were enrolled. Data were collected using the validated 61-item Parental Health Literacy Scale assessing five HL domains. Multiple linear regression with simultaneous variable entry identified independent determinants of overall HL. Among the 380 participants, the largest ethnic group was Thai-Yai (23.95
This article investigates the degree to which adolescent mental health disorders (MHDs) are associated with mothers’ and fathers’ work and welfare trajectories during childhood. Recognizing that children in families with weak labor market ties often face multiple disadvantages, the study also examines how the association between specific family stressors – such as lone parenthood, parental dissolution, and co-parent MHDs – and adolescents’ mental health differs across resource-rich and resource-poor trajectories. Using administrative register data, we followed a cohort born in 1999 from ages 5 to 18. Sequence analysis was used to map parental work and welfare trajectories over nine years (from ages 5 to 13), identifying four distinct clusters: stable employment, work and education, early marginalization, and welfare. Logistic Regression with Average Marginal Effects (AMEs) showed a statistically significant increased risk of MHDs (measured at ages 14–18) among adolescents whose parents followed a welfare trajectory, even after adjusting for the other parents’ trajectory, parental age at childbirth, parental mental disorders, mother’s and father’s income in 2003, family cohabitation structure in 2003, and parental educational level in 2003. Analyses comparing the associations between family stressors and adolescents’ MHDs across parental trajectories indicated two high-risk groups: Girls in lone-parent households where the mother followed an early marginalization trajectory, and children experiencing dual parental disadvantage—one parent in a resource-poor trajectory and the other with an MHD. These results point to the need for policies that address multiple, co-occurring sources of vulnerability to reduce the intergenerational transmission of disadvantage.
Community and stakeholder engagement is widely recognized as essential for equity-oriented health research, yet evidence on how engagement principles are enacted within stratified contexts remains limited. Existing studies often emphasize participatory processes without examining how institutional conditions shape engagement quality and outcomes. Empirical analyses linking engagement practice to equity-relevant research effects are needed. This study examined how principles of inclusivity, reciprocity, social justice, and reflexivity were operationalized within a community-engaged maternal health equity study. A qualitative, theory-informed reflection design was employed within a health equity research project conducted in Madhesh Province of Nepal. Data sources included engagement activities with community and stakeholder participants, structured researcher debriefs, and a facilitated reflexivity workshop. Analysis followed a conceptual framework emphasizing engagement principles, structural mediation, reflexive practice, and proximal outcomes. Data were synthesized through iterative thematic analysis and integrative interpretation across evidence sources. Engagement contributed to trust and transparency through iterative interaction and locally embedded facilitation. Community participation supported the contextual validity of findings by providing experiential knowledge that informed the analytical interpretation of inequities. Reflexive practice enabled adaptive implementation but was unevenly applied, often constrained by institutional timelines, resource limitations, and sociocultural hierarchy. Engagement influenced study design and interpretive framing, contributing to partial redistribution of epistemic authority while remaining structurally bounded. These dynamics illustrate engagement as a negotiated practice shaped by relational positioning and institutional context. Equity-oriented engagement can function as a relational and reflexive mechanism that supports more justice-oriented knowledge production. However, meaningful participation may require institutional conditions that support relational infrastructure, flexible implementation, and reflexive governance. Embedding these conditions within research systems is important for advancing equity-oriented health research practice.
Equitable distribution of the physician workforce is central to health equity. In universal-coverage systems, whether physician supply is aligned with realized inpatient utilization across regions is debated. We examined the concordance between prefectural physician supply and inpatient utilization in Japan and identified prefectures that diverge from the overall pattern. We conducted a cross-sectional ecological analysis of all 47 prefectures using publicly available government data for 2020. The exposure was physician density (physicians per 100,000 population) and the outcome was the inpatient discharge rate (discharges per 100,000 population, summed across the standardized major diagnostic categories). Associations were assessed using Spearman’s rank and Pearson correlations, population-quartile-stratified correlations, Spearman partial correlation adjusting for population aging, and multivariable linear regression adjusting for the percentage of the population aged ≥ 65 years, population size, and population density. Prefectures were cross-classified around national medians into four quadrants. Reporting followed STROBE. Physician density (mean 286.0, SD 51.0 per 100,000) and inpatient discharges (mean 8,556.8, SD 921.3 per 100,000) each showed substantial geographic variation across prefectures. Physician supply was strongly and positively correlated with inpatient utilization (Spearman ρ = 0.75, p < 0.001; Pearson r = 0.73). The association persisted after adjustment for population aging (partial ρ = 0.77) and in multivariable regression (adjusted β = 12.4 additional discharges per 100,000 per one-unit increase in physician density; 95
Ethnic minority women in the United Kingdom experience worse mental health than the general population, yet the mechanisms driving this gap remain unclear. This study examines how much of the gap is explained by differences in social determinants and how much reflects differential returns to those determinants across groups. We used pooled data from 14 waves of the UK Household Longitudinal Study (2010–2024), comprising 291,711 person-wave observations from 50,336 unique individuals. We compared ethnic minority women with the rest of the UK adult population. Mental health was measured using the SF-12 Mental Component Summary and the GHQ-12 Likert scale. Oaxaca-Blinder decomposition with pooled coefficients separated the observed gap into an explained component, mapping to differential exposure in the Diderichsen framework, and an unexplained component, which contains both differential vulnerability and unmeasured factors. A within-women contrast was estimated as a co-equal main analysis, comparing ethnic minority women with white women only. Sensitivity analyses tested the robustness of results to carry-forward imputation, income specification, the inclusion of limiting illness, and within-person clustering. Secondary analyses examined ethnicity without gender and disaggregated ethnic groups. Ethnic minority women scored 1.83 points lower on the SF-12 (p < 0.001) and 0.81 points higher on the GHQ-12 (p < 0.001) than the rest of the population. A substantial share of the SF-12 gap was associated with differences in group characteristics, primarily age composition, home ownership, marital status, and neighbourhood cohesion, although the explained share varied across specifications (38
Unilateral economic sanctions are increasingly recognized as factors associated with structural determinants of health, yet their implications for health service delivery require in-depth examination. In Iran, these pressures appear to extend beyond medicine shortages to affect financing, procurement, infrastructure, workforce capacity, and continuity of care. This policy commentary offers an in-depth analysis of how economic sanctions influence health service delivery in Iran, drawing upon a synthesis of existing literature and expert understanding of the Iranian context. The analysis highlights how sanctions may be linked to disruptions in multiple dimensions of service provision. Reported effects include weakened preventive and immunization services, fiscal and administrative pressures on health institutions, workforce constraints, reduced access to medical equipment and technologies, and diminished patient access to care. These pressures are associated with undermining procurement stability, delay service provision, increase waiting times, and exacerbate existing inequities, particularly in underserved populations and regions. Economic sanctions appear to act as profound structural pressures on Iran’s health system, which may weaken its financial, organizational, and operational capacity. Strengthening health system resilience and safeguarding equitable access to essential services, informed by the challenges identified in this analysis, should therefore be central to policy and humanitarian responses.
Aiming at the practical problems such as upcoding and decomposing hospitalizations emerging in China’s Diagnosis-Related Group (DRG) reform, existing studies mostly attribute such issues to aspects like behavioral motivations, which fail to explain the root causes of the problems. This paper takes policy goals as the research starting point and constructs a three-dimensional analytical framework of “identifying goals-quantifying relationships-explaining mechanisms”. Based on 377 DRG policy texts covering the central, provincial and municipal levels from 2009 to 2025, this study employs the BERTopic model to identify the policy goals of three phases in turn, visualizes the evolutionary characteristics of the goals through Jaccard similarity analysis, and introduces the Lotka-Volterra model to quantify the competitive and cooperative coefficients among the six major policy goals in the national promotion phase, further classifying their relationships into three types: cooperation, predation and competition. The study finds that the policy goal system of China’s DRG reform presents an evolutionary law from fragmented advancement to systematic improvement, with healthcare insurance fund management and controlling healthcare fees as the core thread running through all three phases. The six major policy goals in the national promotion phase are improving primary healthcare levels (G1), standardizing diagnosis and treatment behaviors (G2), controlling healthcare fees (G3), raising the use efficiency of fund (G4), enhancing service quality (G5), and reflecting the technical value of healthcare personnel (G6), among which there exist 6 groups of cooperative relationships, 5 groups of predatory relationships and 4 groups of competitive relationships. Specifically, G5 and G6 exhibit a prominent synergistic effect, while G5 is subject to the triple squeeze from G2, G3 and G4, and G1 is in a competitive relationship with G2, G3 and G4 respectively. From the perspective of policy design, this study reveals that the structural contradictions among DRG policy goals may induce healthcare institutions and healthcare personnel to adopt strategic behaviors under the pressure of multiple goals. This research provides a theoretical basis for optimizing DRG policy design and promoting goal coordination, and also offers reference significance for DRG reforms worldwide.
Abstract Background While genderqueer and nonbinary (GQNB) people comprise a significant percentage of the transgender community, very little research has explored the unique experiences and needs of GQNB patients. A critical challenge faced by GQNB patients is the degree to which health systems operate inside of a gender binary—as evidenced by the design of health technologies, organizational policies, and culture. Understanding how GQNB patients navigate health systems as they currently exist may give us insight into how to improve the design of those systems. This study aimed to identify GQNB patient strategies for navigating care. Methods As part of the TRANS-SAFE study aimed at identifying system contributors to psychosocial safety of transgender and nonbinary patients, we conducted semi-structured interviews with GQNB patients ( n = 21) and clinicians who care for GQNB patients ( n = 23). We performed a deductive content analysis of the transcripts, applying a Human Factors Engineering-based work system model—The Systems Engineering Initiative for Patient Safety 2.0—and then reviewed coded excerpts to identify patient strategies, defined as “any dynamic response to perceived work system barriers to, or facilitators of, timely and effective performance of effortful work activities in pursuit of the patient’s health goals.” Strategies were summarized and grouped by “type” and “purpose” through an iterative, team-based process and work system barriers for each strategy were identified. Results We identified four types of strategies that GQNB patients employed. These strategies included (1) “satisficing” (i.e., accepting a solution, even if unideal, that sufficiently satisfies one’s minimum requirements) around care, (2) leveraging tools/technologies or GQNB community expertise, (3) adjusting their behavior, and (4) taking ownership of their care. GQNB patients used strategies for five different purposes: (A) accessing care, (B) interacting with the health system broadly, (C) interacting with clinicians, (D) navigating clinical settings, and (E) interacting with the EHR. Conclusions GQNB patients use a variety of strategies to ensure they receive appropriate and affirming care. These strategies point to the goals and needs of GQNB patients, yet primarily represent an attempt to receive the bare minimum in person-centered care. In fact, these strategies characterize patient work that is harmfully burdensome for this population. Studying the strategies leveraged by GQNB patients gives us insight into how we might improve health care for all patients.
Abstract Despite three decades of expanding scholarship on social determinants of health (SDH), progress in reducing health inequities has remained limited. While the SDH framework has reshaped global health discourse and informed policy rhetoric, the translation of knowledge into transformative action has been insufficient. The gap between evidence and impact is not explained by political constraints alone but is also contributed to by the orientation, methods, and practices of SDH research itself. We identify key limitations in what is studied, how research is conducted, and who leads knowledge production. Thematic gaps include the dominance of descriptive research, limited evidence on effective policy interventions, insufficient engagement with structural determinants and political economy, and underdeveloped attention to emerging drivers such as climate change, digitalization, and commercial determinants. Methodological limitations include underuse of policy, implementation, modelling, and participatory approaches, alongside persistent data gaps. Deficiencies in research practice constrain the transformative potential of SDH scholarship, including a lack of multi-disciplinary work, limited community and policymaker engagement and leadership, and inequitable power dynamics in global health research itself. We propose a reorientation of SDH research toward agency and action with greater focus on solutions and implementation pathways, methodological pluralism, multisectoral and participatory knowledge production, improved communication and policy engagement, and reforms to research incentives, funding and governance. By repositioning SDH research as an active contributor to political and institutional change, researchers can more effectively support equitable and sustainable health outcomes in a global context increasingly inhospitable for attention to health equity.
Community-based rehabilitation (CBR) is promoted to improve rehabilitation access and social participation for persons with disabilities. In China, Self-Help and Peer Support for Persons with Disabilities (SHPSPD) service is the hybrid CBR service intended to complement clinical rehabilitation by extending self-help and peer-enabled support into community settings. Its early implementation raises an equity-relevant implementation question: whether the service can reach regions and participant groups with sufficient continuity and fit. We conducted a multisite qualitative study of SHPSPD implementation across five regions in a representative eastern Chinese province. Semi-structured interviews and focus groups were conducted with 43 stakeholders. Data were analyzed using deductive-inductive thematic analysis informed by the Consolidated Framework for Implementation Research (CFIR). CFIR construct ratings were assigned by region, and Expert Recommendations for Implementing Change (ERIC) matching was used to identify candidate implementation strategies. Stakeholders valued SHPSPD as a promising hybrid CBR service that could support psychosocial recovery, self-efficacy, family–peer co-participation, and community reintegration. Innovation characteristics and individual agency generally facilitated implementation. Barriers clustered in the outer setting, inner setting, and implementation process, including short-cycle project-based financing, weak medical–social referral pathways, uneven organizational resources, limited needs assessment, weak feedback mechanisms, and activity-count-oriented monitoring. These conditions risked selective reach and uneven continuity, particularly for participants and regions less connected to rehabilitation and disability administration networks. Regional CFIR construct ratings showed an implementation gradient, with higher-performing sites benefiting from stronger leadership, resources, cross-sector collaboration, and learning routines. SHPSPD has potential to extend rehabilitation beyond clinical settings through self-help, peer support, family-peer co-participation, and community reintegration. However, equitable scale-up will require implementation systems that protect its relational peer-support functions while strengthening referral pathways, needs assessment, stable workforce support, and equity-sensitive monitoring. CFIR construct ratings and CFIR-ERIC matching provided a practical route from determinant diagnosis to strategy generation for community-based disability services.
The EQ-5D-5L is a widely used measure of health status that has been increasingly applied to study health inequalities. Despite growing recognition of health as a multidimensional construct, few decomposition studies have simultaneously considered both health dimension and their determinants as sources of inequality. This study fills this gap by providing the first integrated decomposition of socioeconomic-related health inequality in China using the EQ-5D-5L instrument. Using cross-sectional data from a nationally distributed sample of 29,882 Chinese adults, we applied the Erreygers-corrected concentration index (ECI) to measure socioeconomic inequality in EQ-5D-5L utility scores, with household income as the ranking variable. An integrated decomposition framework was developed to jointly quantify the contributions of the five EQ-5D-5L dimensions and their associated determinants to overall health inequality. This framework not only identifies the leading dimensions and determinants but also quantifies how determinants contribute to overall inequality through specific dimensions. The estimated ECI for overall EQ-5D-5L utility scores was 0.0275 (95
